Student Name
Capella University
NURS-FPX4015 Pathophysiology, Pharmacology, and Physical Assessment: A Holistic Approach to Patient-Centered Care
Prof. Name
Date
Waiver and Consent Form
Institution: Capella University Course: NURS4015 or NURS-FPX4015
I, ___________(“Participant”), willingly consent to participate as a mock patient in the health assessment video demonstration conducted by ____________(“Student”), who is enrolled in the nursing program at Capella University.
In consideration of participation, I acknowledge and agree to the following terms and conditions:
Purpose of the Waiver
The primary objective of this waiver is to outline how the created content will be used. The content will serve strictly educational purposes and may include:
- Demonstrating clinical health assessment techniques and skills for academic grading.
- Completing a comprehensive academic examination that includes a SOAP (Subjective, Objective, Assessment, Plan) note as described in the course syllabus.
- Providing hypothetical health-related information for simulated clinical practice assignments.
I acknowledge that I waive the right to review or approve the final content prior to its academic use.
Content Definition
I consent to being video recorded for the purposes of the assignment. The Content is defined as:
| Content Component | Description |
|---|---|
| Video Recording | A recorded demonstration featuring the student conducting health assessments. |
| Personal Depiction | My image, likeness, voice, and appearance captured during the recording. |
| Educational Input | Any information provided for the SOAP note or simulation, which may include hypothetical or actual data. |
This may involve both real readings (e.g., vital signs) and hypothetical health information, depending on the assignment requirements.
Disclosures
I fully understand that:
- The information recorded is for academic demonstration only and does not represent actual medical care or advice.
- Disclosure of personal health history is not mandatory. Only basic demographic details (such as age and gender) may be real, while all other health data can remain hypothetical.
- If any vital signs or clinical measures are taken, they may reflect my actual physiological readings, though their use will remain in an educational context.
Voluntary Consent and Use
I provide voluntary and unrestricted permission for Capella University to:
- Use, display, distribute, and reproduce the content for educational purposes.
- Share the content with instructors, faculty members, and relevant staff within the institution for assessment and training purposes.
I acknowledge that I waive the right to inspect the content before use and also forfeit any future claims for financial or non-financial compensation related to the content’s use.
Rights and Ownership
All recorded material will remain the exclusive property of Capella University. By participating, I:
- Assign full ownership rights to the university.
- Release Capella University from all potential claims related to the use, ownership, or creation of the content.
- Understand that no personal rights regarding publicity, privacy, or reproduction will be retained by me
Waiver and Release of Liability
I hereby release and discharge Capella University, its affiliates, trustees, faculty, staff, students, and representatives from any liability for harm, injury, damages, claims, costs, or expenses that may result from the recording, storage, distribution, or use of the content.
Governing Law
This waiver shall be governed under the laws of the State of Minnesota. Any disputes or legal actions arising from this agreement will be resolved exclusively within the state or federal courts located in Minnesota.
Acknowledgement and Agreement
By signing below, I affirm that:
- I am at least 18 years of age.
- I have carefully read, understood, and agreed to the conditions outlined in this waiver.
Student Information
- Signature: ___________________________
- Date: 24-06-2025
- Printed Name: ___________
Participant Information
- Signature: ____________ ___
- Date: 28-06-2025
- Printed Name: _____________References
Capella University. (2025). NURS4015: Health assessment course materials. Minneapolis, MN: Capella University.
American Nurses Association. (2023). Consent, privacy, and confidentiality in nursing practice. ANA Publications.
NURS FPX 4015 Assessment 1 Waiver and Consent Form
National Institute of Health. (2024). Guidelines for informed consent in educational and clinical simulations. NIH.